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Cases/ECGs: the Cardiac PatientPrimary Care UpdateDept of Family and Community MedicineOctober 17, 2020
UMAIR KHALID, MDVIJAY NAMBI, MDARUNIMA MISRA, MD
No disclosures
Normal
Methodical Way to Approach ECGRate rhythm axis
P wave and PR
QRS
ST and T waves
If find something abnormal, compare to old ECG to see if new changes
34 yo man with psychiatric problems including depression and PTSD presents with atypical chest pain. No history of HTN or other risk factors. No associated symptoms.
Anything concerning?
34 yo with atypical chest pain:
A. STEMI
B. LVH
C. Early repolarization
D. Pericarditis
C. Early repolarization
Early Repolarization
https://en.ecgpedia.org
71M w diabetes, in clinic waiting area, collapses on the ground, clenching his chest.
Features of EKG favoring STEMIMorphology of ST elevation
Reciprocal changes
Dynamic changes
Presence of Q waves (late)
ST elevation
What to do?When in doubt, compare with previous EKG. Can also repeat EKG.
If concern for acute MI, active the STEMI pager and notify cardiology emergently
If the hospital/facility does not have PCI-capable cath lab, will have to immediately arrange for EMS
Coronary Angiogram
43 year old male, with intermittent sharp chest pain on breathing, gets better with leaning forward, gets worse with lying on back
Features of PericarditisWidespread concave ST elevation and PR depression throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6).
Reciprocal ST depression and PR elevation in lead aVR (±V1).
Sinus tachycardia is also common in acute pericarditis due to pain and/or pericardial effusion.
Causes of PericarditisInfectious – mainly viral (e.g. coxsackie virus); occasionally bacterial, fungal, TB.
Immunological – SLE, rheumatic fever
Uremia
Post-myocardial infarction / Dressler’s syndrome
Trauma
Following cardiac surgery (post pericardiotomy syndrome)
Paraneoplastic syndromes
Drug-induced (e.g. isoniazid, cyclosporin)
Post-radiotherapy
79 yo man complaining of blurred vision and headache and presented to the ED. No chest pain or SOB.
What do you think about ECG?A. STEMI
B. NSTEMI
C. Concern for LVH
D. Concern for ischemiaD. Concern for ischemia
What would you do next?Choose one or more of the following:
A. Nothing since pt is not having chest pain
B. Compare the ECG to previous ECGs
C. Check a troponin
D. Repeat another ECG
Next stepsNo repeat ECG was done since old ECG was exactly the same
Troponin <0.03
Recommend echo and NST for risk stratification given findings (he never had)
Previous ECG evaluated
59 y/o AAM w/ PMHx of Tobacco use, polysubstance abuse presenting to ER w/ c/o feeling like throat tightening and closing, little heart burn sensation intermittently over the last 2 days. Pt states some intermittent SOB.
What is concerning on the ECG?
A. ST elevation
B. ST depression
C. T wave inversions
D. No concerning changes
C. T wave inversions
What should you do?Compare with previous/old ECG and see if changes are new
Send pt to ED by ambulanceTroponin 1.26
Went to cath lab
70% LM and sent for CABG
76 yo man with HLD, HTN, CAD, s/p PCI to RCA and LCx and mild ICMP with EF of 45% presents for preop assessment of cataract surgery.No CP or SOB. Good functional status
Should we be concerned?What is the abnormality on the ECG?A. LBBB
B. LVH
C. RBBB
D.ST depression concerning of ischemia
RBBB: ECG criteria for a right bundle branch block include the following:
QRS duration greater than 120 milliseconds
rsR’ “bunny ear” pattern in the anterior precordial leads (leads V1-V3) but no beyond
Slurred S waves in leads I, aVL and frequently V5 and V6
RBBBCAUSES OF RBBB
Congenital heart disease such as atrial septal defect
Myocardial infarction
Myocarditis
Pulmonary hypertension
Pulmonary embolus
Mayo Clinic.org
Damage or abnormality in the conduction system involving the fibers in the right bundle of the heart
Can be congenital or acquired
May not always be pathological
An echocardiogram may be helpful
IMPLICATIONS OF RBBB
71 yo man paraplegic, PAD, hx of DVT, presents with cholecystitis and s/p cholecystectomy with acute hypoxia and tachycardia
Pulmonary embolus or not?
ECG findings for PESinus tachycardia
Complete or incomplete RBBB
Right ventricular strain pattern: Tw inversions in V1-4 and/or inferior leads ((classic: S1Q3T3)
Right axis deviation
Dominant R wave in V1
Right atrial enlargement (leas II with 2.5 mm P wave)
84 y/o M with PMH of DM, HTN, HLD, CAD, BPH, hx of seizure and severe right hip osteoarthritisECG done as preop assessment
What is the diagnosis?A. ST depression suggestive of
ischemia
B. LBBB
C. LVH with repolarization changes
D. STEMI
LVH CriteriaVoltage criteria
Repolarization changes ◦ ST depression, limb and V4-6
◦ Discordant ST elevation in V1-3
Left atrial enlargement
Left axis deviation
QRS widening
Multiple criteria for increased voltage
Limb Leads
R wave in lead I + S wave in lead III > 25 mm
R wave in aVL > 11 mm (most specific)
R wave in aVF > 20 mm
S wave in aVR > 14 mm
Precordial Leads
R wave in V4, V5 or V6 > 26 mm
R wave in V5 or V6 plus S wave in V1 > 35 mm
Largest R wave plus largest S wave in precordial leads > 45 mm
https://litfl.com/left-ventricular-hypertrophy-lvh-ecg-library/
Causes of LVHHypertension (most common cause)
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Coarctation of the aorta
Hypertrophic cardiomyopathy
Voltage criteria alone are not diagnostic of LVH
ECG changes are an insensitive means of detecting LVH (patients with clinically significant left ventricular hypertrophy seen on echocardiography may still have a relatively normal ECG) or vice versa (not specific unless meet all criteria)
71 yo man with HTN, DM, HLD and exertional dyspnea for past few months. He can push a lawn mower for 5-6 min. Also with fatigue.
What is wrong with the ECG?
A. Ventricular tachycardia
B. LBBB
C. RBBB
D. STEMI
LBBB
CRITERIA
QRS duration of > 120 ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
ASSOCIATED FINDINGS
Appropriate discordance: the ST segments and T waves always go in the opposite direction to the main vector of the QRS complex
Poor R wave progression in the chest leads
Left axis deviation
Causes of LBBBMyocardial infarction
Cardiomyopathy
Myocarditis
Hypertension (LVH with extreme QRW widening progression)
Our caseCAD
LVH
Underwent CABG
88 yo M w/ Parkinson's disease, BPH, CAD w/ prior CABG (1989) presents with UTI and also has chest pain
What is the diagnosis?
A. Sinus bradycardia
B. Complete heart block
C. Ectopic atrial rhythm
D. Atrial fibrillation
81 y/o M with PMH of HTN, BPH, C3-5 cervical fusion, who presented 1 week after LOC with fall with 3-4 days of generalized weakness and SOB.
What’s the diagnosis?A. Atrial fibrillation
with slow ventricular response
B. Myocardial infarction
C. Complete heart block
D. Pacemaker malfunction
Complete heart block
DEFINITION
Complete absence of AV conduction; no relationship between P wave and QRS complexes
P rate is faster than R to R rate
Generally, there is junctional or ventricular escape rhythm
If inadequate escape rhythm, there may be syncope if self –terminated or death if prolonged
CAUSES
Myocardial infarction (inferior with increase in vagal tone or anterior if entire septum is infarcted
Medications: CCB, BB or digoxin
Idiopathic degeneration of the conducting system (Lenegre’s or Lev’s disease)
71 year old MALE with current tobacco smoker with h/o CVA, HTN, T2DM, paroxysmal aflutter w/ RVR presented from nursing home for feeling dizzy
What does the ECG show?
A. Atrial flutter
B. Atrial tachycardia
C. Atrial fibrillation
D. Sinus tachycardia
Causes of Sinus TachycardiaDrugs (methamphetamines, amphetamines, cocaine)
Caffeine
Alcohol
Hyperthyroidism
Fever
Infection
Volume depletion
Anemia
Heart failure
Myocardial infarction
Pulmonary embolus
Anxiety
Pain
Inappropriate sinus tachycardia (least common, about 1.2% of the population may have)
Our patient had hemoglobin of 6.1
74M with prior hx of CABG, presented with palpitations
Features of Atrial FlutterNarrow complex tachycardia
Regular atrial activity at ~300 bpm
Flutter waves (“saw-tooth” pattern) best seen in leads II, III, aVF — may be more easily spotted by turning the ECG upside down!
Flutter waves in V1 may resemble P waves
Loss of the isoelectric baseline
23 year old pregnant female with sudden onset palpitations
Supraventricular TachycardiaRegular narrow complex tachycardia (often the rate = ~150 bpm)
QRS complexes usually narrow (< 120 ms) unless pre-existing bundle branch block, accessory pathway, or rate related aberrant conduction.
ST-segment depression may be seen with or without underlying coronary artery disease.
P waves if visible exhibit retrograde conduction P waves may be buried in the QRS complex, visible after the QRS complex, or very rarely visible before the QRS complex.
69 year old male with PMH significant for HTN, HLD, DM, HFrEF, VT w/ cardiac arrest s/p AICD, CAD s/p PCI (LAD) presents with palpitations after running out of meds
What’s the diagnosis?
A. Multifocal atrial tachycardia
B. Atrial fibrillation
C. Atrial flutter
D. Atrial tachycardia
62 yrs old male with ESRD on HD, stage IV colon cancer, HF, PHTN, Hep C who complains of worsening SOB and found to have pneumonia
A. Atrial tachycardia
B. Atrial fibrillation
C. Atrial flutter
D. Multifocal atrial tachycardia
16 yo coming for high school physical
ECG features to look for:
1. LVH
2. Q waves (very narrow)
3. ST depression/T wave inversions to suggest repolarization changes
4. Left atrial enlargement
5. Pre-excitation
https://medscape.com
30 yo presented with exertional lightheadness and palpitations
LVH
Narrow Q waves in I, V4-V6
Classic HCM with septal hypertrophy
https://litfl.com
Early repolarization
Sinus bradycardia
Right bundle branch block
Pt with history of CP
Poor R wave progression suggestive of old anterior
myocardial infarction
LBBB
CP
ST Depression suggestive of ischemia
Atrial Flutter
Q waves inferiorly suggestive of old inferior
myocardial infarction
Atrial Fibrillation
ST depression suggestive of ischemia
ESRD with K of 5.9
INFERIOR STEMI
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